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Benefits and Cost-Sharing for Working People with Disabilities in Medicaid and the Marketplace

Appendix 1

Table 4: Selected Benefits Covered Through Medicaid and the Marketplace in California
Benefit Type Medicaid State Plan Medicaid New Adult ABP Marketplace QHP
Mental health and substance use treatment services
-Outpatient mental health, including individual and group evaluation and therapy, psychological testing, outpatient monitoring of drug therapy, labs, drugs, supplies, supplements, screening and brief intervention, psychiatric consultation for medication management
-Outpatient heroin detox services
-Other licensed practitioners (psychologists)
-Rehab services, including mental health services, medication support, day treatment intensive, day rehab, crisis intervention, crisis stabilization, adult residential treatment, crisis residential, and psychiatric health facility services
Same as state plan
-Inpatient psychiatric hospitalization and intensive psychiatric treatment programs
-Substance abuse disorder inpatient detox
-Mental/behavioral health outpatient services* for diagnosis and treatment
-Substance abuse disorder outpatient services, including day treatment, intensive outpatient, individual and group counseling, and medical treatment for withdrawal symptoms
Prescription drugs Covered Same as state plan Generic, preferred brand, non-preferred brand, and specialty drugs
Rehabilitative and habilitative services and devices
-Durable medical equipment (prior authorized)
-Medical supplies
-Prosthetic and orthotic appliances
-Physical, occupational and speech therapy and audiology
-Outpatient rehab center services
-Specialized rehab services in skilled nursing and intermediate care facilities
-Skilled nursing facility (90 days)
Same as state plan 
-Skilled nursing facility (100 days/year)
-Outpatient rehab services, including physical, occupational and speech therapy
-Habilitation services*
-Durable medical equipment (prior authorized)
Long-term services and supports
-Community Based Adult Services
-Case management/targeted case management
-Home health services – skilled nursing, home health aide, physical, occupational and speech therapy and audiology, and medical social work services
-ICF/DD
-Multipurpose Senior Services Program
-Personal care services, including self-direction
-Skilled nursing facility (over 90 days)
-Private duty nursing
-Community First Choice attendant care services and supports
Same as state plan (beneficiary must meet medically frail criteria to access LTSS) -Home health care services (100 visits/year, up to 2 hours/visit, 3 visits/day; nurse, master’s level social worker, physical/occupational/speech therapist)
NOTES: *State required benefits (outpatient mental health coverage for severe mental illness, hab services for behavioral health treatment of autism and related disorders).
SOURCES: CA state Medicaid plan benefits information from CA § 1115 Bridge to Reform Demonstration Special Terms and Conditions, available at http://www.dhcs.ca.gov/provgovpart/pages/waiverrenewal.aspx; CA New Adult ABP, SPA#CA- 13-035, available at www.medicaid.gov; QHP coverage based on Marketplace EHB benchmark plan, Kaiser Foundation Health Plan Small Group HMO 30 ID, and state required benefits, available at www.cms.gov/CCIIO/Resources/ehb.html.
Table 5: Cost-Sharing in Medicaid and the Marketplace in California
Cost-Sharing Type Medicaid State Plan Medicaid New Adult ABP Marketplace QHP
Monthly premiums 0 Same as state plan
$108 with APTC
($245 without APTC;APTC = $137)
Annual Deductible N/A Same as state plan $1,500 medical; $250 brand Rx
Out-of-pocket maximum Per federal law, cost-sharing shall not exceed 5% of total family income ($201/quarter, or $804/year, for an individual based on quarterly earnings of 138% FPL) Same as state plan $5,200
Co-pays for selected services N/A Same as state plan
-$40 primary care physician visit
-$50 specialist visit
-$19 generic Rx
-$250 ER
NOTES: CA QHP information based on single, non-smoker, age 35, 145% FPL ($1,388/month), L.A. County, www.healthcare.gov.
SOURCES: State Medicaid Plan information available at http://www.dhcs.ca.gov/formsandpubs/laws/Pages/CaliforniStatePlan.aspx; APTC based on KFF subsidy calculator, http://kff.org/interactive/subsidy-calculator/; CSR for Health Net Enhanced Silver 73 HMO available at www.healthcare.gov.

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Table 6: Selected Benefits Covered Through Medicaid and the Marketplace in Kentucky
Benefit Type Medicaid State Plan* Medicaid New Adult ABP Marketplace QHP**
Mental health and substance use treatment services
-Inpatient mental health services (prior authorization; no IMD services for 21-64)
-Outpatient psychiatric services (4/year unless rendered by board-eligible or board-certified psychiatrist)
-Mental health center services
-Preventive chronic disease services for depression
-Screening, assessment, and psychological testing
-Crisis intervention, mobile crisis and residential crisis stabilization
-Peer and parent/family support
-Individual and group outpatient therapy (3 hours/day each, exceed if medically necessary)
-Family outpatient therapy
-Intensive outpatient services and partial hospitalization
-Substance use disorder screening, brief intervention, referral, residential services, medication assisted treatment
-Mental health assertive community treatment, comprehensive community support services, and therapeutic rehabilitative program
-Service planning and case management
-For those under age 21, collateral outpatient therapy and day treatment
Same as state plan
-Mental/behavioral health and substance abuse disorder inpatient services (30 days/ for mental health and substance use combined; 2 inpatient and outpatient substance abuse rehab programs per lifetime)
-Mental/behavioral health and substance abuse disorder outpatient services (30 visits/year for mental health and substance use combined)
The above services include partial day mental health and substance abuse services, intensive outpatient programs, and residential treatment services.
Prescription drugs Provided (subject to preferred drug list, may require prior authorization) Same as state plan Generic, preferred brand, non-preferred brand, and specialty drugs
Rehabilitative and habilitative services and devices
-Durable medical equipment, medical supplies, prosthetics and orthotics (some exclusions, some items subject to prior authorization)
-Nursing facility (90 day rehab stay)
-Physical, occupational, and speech therapy (prior authorization, combined 20 inpatient and outpatient visits per type of therapy per year including both rehab and hab, prior authorization for medically necessary additional visits)
Same as state plan 
-Durable medical equipment, devices, supplies, prosthetics and appliances (some exclusions)
-Skilled nursing facility services (90 days/year)
-Rehab facilities (60 days/year)
-Outpatient rehab and hab services, including physical, occupational, speech, pulmonary, and cardiac rehab therapy (20 visits per type of therapy per year, including both rehab and hab*** for physical, occupational and speech therapy, except 36 visits/year for cardiac rehab)
Long-term services and supports
-Long-term care nursing facility services (must meet criteria for “high intensity,” “low intensity” or ICF/IDD, prior authorization, re-evaluated every 6 months)
-Home health services, including intermittent or part-time nursing (prior authorization, includes disposable medical supplies) and home health aide services (prior authorization)
-Private duty nursing (up to 2,000 hours per year with prior authorization, exceed if medically necessary)
Same as state plan
-Home health care services*** (100 visits/year, including nurse, therapist, home health aide, and physical, occupational, and speech therapy)
-Private duty nursing (2,000 hours/year)
NOTES and SOURCES: *KY uses an ABP for currently eligible beneficiaries (SPA#KY-13-021); KY State Medicaid Plan, available at http://chfs.ky.gov/dms/State+Plan+Amendments.htm; KY New Adult ABP, SPA#KY-13-020, available at www.medicaid.gov. **QHP coverage based on Marketplace EHB benchmark plan, Anthem BCBS Blue 6 Blue Access PPO Medical Option D4 Rx Option G and state required benefits, available at www.cms.gov/CCIIO/Resources/ehb.html; ***KY state required benefit. (Hab services required for autism spectrum disorders).
Table 7: Cost-Sharing in Medicaid and the Marketplace in Kentucky
Cost-Sharing Type Medicaid State Plan Medicaid New Adult ABP Marketplace QHP
Monthly premiums 0 Same as state plan $117 with APTC($262 without APTC;APTC = $145)
Annual Deductible N/A Same as state plan $200 with CSR($2,500 without CSR)
Out-of-pocket maximum Cost-sharing shall not exceed 5% of total family income for a quarter ($201/quarter, or $804/year, for an individual based on quarterly earnings of 138% FPL) Same as state plan $600/year including deductible with CSR($6,350 without CSR)
Co-pays for selected services
-$50.00 per inpatient hospital admission
-$4.00 for outpatient hospital services
-$3.00 for physician services/office visits with physical and behavioral health providers
-$1.00 for preferred and non-preferred generic drugs and atypical anti-psychotics without generic equivalent
-$4.00 for preferred brand name drugs without generic equivalent and available under supplemental rebate program
-$8.00 for non-preferred brand name drugs
-$3.00 per visit for physical, occupational and speech therapy
-$4.00 per date of service for durable medical equipmentPreventive services are not subject to co-paysCertain populations are exempt from Medicaid cost-sharing under federal law
Same as state plan
-$10 primary care physician visit with CSR, not subject to deductible for 1st 3 visits, 10% after deductible for additional visits($40 without CSR, 1st 3 visits subject to co-pay, additional visits subject to deductible and 10% coinsurance after deductible)
-10% after deductible for specialist visit with CSR(same without CSR)
-$10 not subject to deductible for generic drugs with CSR($15 without CSR)
-$75, then deductible and 10% for emergency room visit with CSR ($200 copay before deductible without CSR)
NOTES: KY QHP information based on single, non-smoker, age 35, 145% FPL ($1,388/month), Jefferson County, Kynect, https://kyenroll.ky.gov/PreScreening/PreScreeningOverView.
SOURCES: KY State Medicaid Plan, available at http://chfs.ky.gov/dms/State+Plan+Amendments.htm; APTC based on KFF subsidy calculator, http://kff.org/interactive/subsidy-calculator/; CSR for Anthem BCBS Silver DirectAccess PPO – dbds, available at https://www.anthem.com/health-insurance/kentucky/health-plans/.
Table 8: Selected Benefits Covered Through Medicaid and the Marketplace in New Jersey
Benefit Type Medicaid State Plan Medicaid New Adult ABP Marketplace QHP
Mental health and substance use treatment services
-Mental health rehab, inpatient, and outpatient services
-Inpatient and outpatient substance use services
-Mental health clinic services
-Methadone maintenance
-Partial care
-Partial hospitalization-Inpatient psych under 21/over 65
-Residential treatment center
-Case management-Personal care services for mental health (25 hours/week)
-Inpatient mental health and psychiatric services
-Inpatient hospital medical detox-Non-hospital based detox (including individual and group counseling)
-Outpatient substance use disorder services (including intake, assessment, physician services, individual, group and family counseling)
-Substance use partial care (including physician services, lab, individual, group and family counseling),
-Substance use intensive outpatient (including physician services, individual, group, and family counseling)
-Substance use short-term residential (including individual, group, and family therapy)
-Partial hospitalization
-Outpatient hospital and clinic mental health services
-Community support services
-Program of assertive community treatment services
-Case management
-Community mental health rehab services, including psychiatric emergency rehab
-Behavioral health home services
-Opioid treatment/maintenance
-Mental health adult rehab (group homes)
-Mental/behavioral health and substance abuse disorder inpatient services (prior authorized)
-Mental/behavioral health and substance abuse disorder outpatient services
Substance abuse disorder inpatient and outpatient treatment of alcoholism and coverage of biologically based mental illness are state required benefits
Prescription drugs Covered Same as state plan Generic, preferred brand, non-preferred brand, and specialty drugs
Rehabilitative and habilitative services and devices
-Durable medical equipment-Rehab services (60 consecutive days/year)
-Rehab hospital services-Medical suppliesOrthoticsProsthetics
-Outpatient rehab, including physical, occupational and speech therapy
-Physical, occupational, and speech therapy – rehab and hab (prior authorization)
-Home-based habilitative services (§ 1915(i))
-Prosthetics (prior authorization above certain dollar amounts)
-Outpatient rehab (30 visits/year, prior authorized)
-Speech and cognitive therapy (30 visits/year – rehab and hab)
-Physical and occupational therapy (30 visits/year – rehab and hab)
-Durable medical equipment* (prior authorized)
-Autism/DD hab and rehab services* – physical, occupational, and speech therapy (30 visits/year) and applied behavioral analysis (under age 21)
Long-term services and supports
-Home health services-ICF/DD-Medical day care
-Nursing facility services
-Personal care services
-Private duty nursing (prior authorization)
-Respite care-Skilled nursing facility
-Home health services, including nursing, home health aide, medical supplies, equipment, and appliances for home and physical, occupational, and speech therapy
-Clinic services – medical day care (12 hours/day, prior authorized)
-Adult day health services (§ 1915(i))
-Personal care services, including self-direction (40 hours/week)
-Nursing facility/skilled nursing facility services (prior authorized)
-Home health care services* (60 visits/year, prior authorized, includes private duty nursing and supplies)
-Skilled nursing facility (prior authorized)
NOTES/SOURCES: * = state required benefit. State plan benefits information: CMS Special Terms and Conditions, NJ Comprehensive Waiver Demonstration, Attachment B, Demonstration Benefits, Plan A (Oct. 1, 2012-June 30, 2017) (http://www.state.nj.us/humanservices/dmahs/home/CMW_STCs.pdf). NJ New Adult ABP (SPA#13-0028), (www.medicaid.gov).QHP coverage based on Marketplace EHB benchmark plan, Horizon HMO Access HSA Compatible and state required benefits (www.cms.gov/CCIIO/Resources/ehb.html).
Table 9: Cost-Sharing in Medicaid and the Marketplace in New Jersey
Cost-Sharing Type Medicaid State Plan Medicaid New Adult ABP Marketplace QHP
Monthly premiums None Same as state plan
$48 with APTC
($304 without APTC;
APTC = $256)
Annual Deductible N/A Same as state plan $100
Out-of-pocket maximum N/A Same as state plan $750
Co-pays for selected services None Same as state plan
-$15 primary care physician visit after deductible
-$30 specialist visit after deductible
-$7 generic drug
-$65 ER visit after deductible
NOTES: NJ QHP information based on single, non-smoker, age 35, 145% FPL ($1,388/month), Bergen County, www.healthcare.gov.
SOURCES: NJ State Medicaid Plan A information available at http://www.njfamilycare.org/income.aspx; APTC based on KFF subsidy calculator, http://kff.org/interactive/subsidy-calculator/; CSR for AmeriHealth NJ Tier 1 Advantage Silver EPO H.S.A., available at www.healthcare.gov.
Table 10: Selected Benefits Covered Through Medicaid and the Marketplace in Ohio
Benefit Type Medicaid State Plan Medicaid New Adult ABP Marketplace QHP
Mental health and substance use treatment services
-Inpatient hospital services (including by psychologists; no IMD services for 21-64)
-Licensed psychologist services (specified procedures; in non-hospital setting, psychological testing limited to 8 hours/year and therapeutic visits and diagnostic interviews limited to combined 25 service dates/year; diagnostic interview limited to 1 per beneficiary/ year)
-Advanced practice nurses’ services (includes psychiatric clinical nurse specialists)
-Clinic services, including FFS ambulatory health care clinics for behavioral health-Rehabilitative services provided by community mental health facilities, including:
–behavioral health counseling and therapy (52 hours/year)
–mental health assessment services (4 hours/year if by non-physician and 2 hours/year if by physician)
–pharmacologic management services (24 hours/year)
–partial hospitalization (minimum 2 hours and up to maximum 16 hours/day)
–crisis intervention mental health services
–community psychiatric supportive treatment (104 hours/year; additional hours if medically necessary and prior authorized)
-Rehabilitative services provided by alcohol and other drug treatment programs, including:
–ambulatory detoxification–assessment–crisis intervention
–group counseling*
–individual counseling*
–intensive outpatient services
–laboratory urinalysis
–medical/somatic services* (such as physical examinations, health assessments, vital signs, reviewing lab findings, medication administration services, medication assisted treatment and dispensing of medications in an alcohol or other drug treatment program)
— opioid agonist administration* Group counseling, individual counseling and medical/somatic services limited to 30 cumulative hours/person/week
-Health home services for beneficiaries with a serious mental health condition (available in certain counties, provided by community behavioral health centers), including comprehensive care management, care coordination, health promotion services, comprehensive transitional care services (from inpatient to other settings), individual and family support services, referral to community and social support services
-Case management services for people with chronic mental illness and beneficiaries receiving alcohol or substance use disorder treatment program services
Same as state plan, except that quantitative limits on mental health outpatient services, alcohol and drug intensive outpatient services, and psychologist services do not apply
-Mental/behavioral health and substance abuse disorder inpatient services (30 days/year combined for non-biologically based mental illness*)
-Mental/behavioral health and substance use disorder outpatient services (30 visits/year combined for non-biologically based mental illness*)
These services include partial day and intensive outpatient programs, 2 days of which are equivalent to 1 day inpatient.
Substance abuse disorder services limited to 2 inpatient and outpatient rehab programs/year for non-biologically based mental illness.*Biologically based mental illness is covered the same as any other medical service.
Prescription drugs Provided (subject to preferred drug list, may require prior authorization) Same as state plan Generic, preferred brand, non-preferred brand, and specialty drugs
Rehabilitative and habilitative services and devices
-Clinic services, including outpatient rehab and speech-language/audiology clinics
-Prosthetic devices (require authorization)-Medical supplies, equipment, and appliances suitable for us in the home (some items require prior authorization)
-Physical, occupational, and speech therapy/ audiology services (30 visits/year per service type in a non-institutional setting, additional visits prior authorized);
-Mechanotherapy services (massage therapy; includes treatment services but not maintenance services)
Same as state plan 
-Skilled nursing facility (90 days/year)
-Rehab facilities (60 days/year)
-Outpatient rehab (physical, occupational, speech, pulmonary and cardiac rehab; 20 visits/year for each type, except 36 visits for cardiac)
-Durable medical equipment, devices, supplies, prosthetics, and appliances (some exclusions)
Long-term services and supports
-Nursing facility services (requires level of care)
-ICF/IDD services (requires level of care)
-Home health services, including intermittent or part-time nursing and home health aide services (limited to combined 8 hours/day together with physical, occupational, and speech therapy and audiology; each service type shall not exceed 4 hours/visit; intermittent or part-time nursing and home health aide services limited to combined 14 hours/week; additional services authorized if medically necessary)
-Private duty nursing,* including
–skilled care post-hospital services up to 56 hours/week during 60 days after discharge from a 3 day or more inpatient stay (excludes maintenance care)–services for beneficiaries up to age 21 with authorization
–services for beneficiaries age 21 and older with authorization who require continuous nursing, including ongoing maintenance care and where beneficiary requires level of care comparable to an institution
* PDN visits are typically more than 4 but less than or equal to 12 hours; must be 2 or more hour lapse between home health intermittent or part-time nursing services and PDN, except for unusual occasional circumstance requiring up to 16 hour visit, or if less than 2 hour lapse and the length of PDN services requires the agency to provide a change in staff, or where the PDN service is provided by more than one non-agency provider, or if PDN visits are authorized for 4 hours or less
-Case management services for people with developmental disabilities
Same as state plan
-Home health care services, including nurse, therapist, home health aide, physical, occupational, and speech therapy (100 visits/year)
-Private duty nursing ($50,000/year; $100,000/lifetime)
SOURCES: OH State Medicaid Plan, available at http://medicaid.ohio.gov/MEDICAID101/MedicaidStatePlan.aspx; APTC; OH New Adult ABP (SPA#13-0032), available at www.medicaid.gov; QHP coverage based on Marketplace EHB benchmark plan, Blue 6 Blue Access PPO Medical Option D4 Rx Option G, and state required benefits summary, available at www.cms.gov/CCIIO/Resources/ehb.html.
Table 11: Cost-Sharing in Medicaid and the Marketplace in Ohio
Cost-Sharing Type Medicaid State Plan Medicaid New Adult ABP Marketplace QHP
Monthly premiums 0 Same as state plan
$49 with APTC
($235 w/o APTC; APTC = $186)
Annual Deductible N/A Same as state plan $100
Out-of-pocket maximum
Per federal law, cost-sharing shall not exceed 5% of total family income
($201/quarter, or $804/year, for an individual based on quarterly earnings of 138% FPL)
Same as state plan $2,250
Co-pays for selected services
-$3.00 for prescription drugs not on preferred list
-$2.00 for selected single-source prescription drugs
Same as state plan
-Primary care doctor, specialists, and ER visits: 5% coinsurance after deductible
-Generic prescription drugs: $5 copay after deductible
NOTES: OH QHP information based on single, non-smoker, age 35, 145% FPL ($1,388/month), Cuyahoga County, www.healthcare.gov. QHP cost-sharing reflects cost-sharing reduction subsidies.SOURCES: OH State Medicaid Plan, available at http://medicaid.ohio.gov/MEDICAID101/MedicaidStatePlan.aspx; APTC based on KFF subsidy calculator, http://kff.org/interactive/subsidy-calculator/; CSR for Kaiser Foundation Health Plan Silver 1750/25%/H.S.A., available at www.healthcare.gov.
Looking Ahead Appendix 2

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